Before certain care, your health plan wants to approve it first. Learn what triggers prior authorization, how long decisions take, and your options after a denial.
This guide is general information, not insurance, tax or legal advice. Rules, limits and deadlines change each year, so check HealthCare.gov, Medicare.gov or your insurer for your situation.
Key points
- Prior authorization is your plan’s advance approval for a service or prescription; the request goes in before care, not after.
- Many plans must decide medical prior authorization requests within 72 hours if urgent and 7 calendar days if standard.
- Emergency services must be covered without prior authorization, regardless of whether the provider or facility is in network.
- If a request is denied, you can file an internal appeal, and the plan must explain how to ask for an external review.
- Keep written records: denial letters, copies of forms, and notes from every call, with dates, times and names.
Many health plans will not pay for certain tests, treatments or medications until the plan approves them in advance. That requirement, called prior authorization, catches many patients off guard when a doctor’s order alone is not enough. Here is how the process works, how long decisions should take, and what to do when a request is delayed or denied.
What Prior Authorization Is and Why Insurers Use It
Prior authorization is your health plan’s advance approval for a medical item, service or prescription. Your doctor submits a request, usually with medical records, and the plan decides whether the care is medically necessary and covered under your plan’s rules. The request goes in before care, which distinguishes it from a claim filed afterward.
Insurers describe prior authorization as a safeguard. Medicare says its programs are meant to protect access to medically necessary items and services while reducing improper billing. The trade-off is paperwork: the Centers for Medicare & Medicaid Services (CMS) estimates that completing prior authorizations costs providers $20 to $50 per hour and takes an average of 13 hours per week, roughly $34,000 and 700 hours per provider each year.
Leading health plans have announced they eliminated 11% of prior authorizations, about 6.5 million fewer requests, and electronic prior authorization becomes mandatory for certain CMS-regulated plans starting January 1, 2027.
Services and Prescriptions That Commonly Require Approval
Requirements vary by plan, so check your plan documents or Summary of Benefits and Coverage. Plans generally reserve prior authorization for higher-cost items. In Medicare, current programs cover certain hospital outpatient department services, durable medical equipment, prosthetics, orthotics and supplies, scheduled non-emergency ambulance transport, and home health services.
Prescription drugs can require approval too. Marketplace plans must cover prescription drugs as one of 10 essential health benefits, but a plan can still require advance approval for particular medications.
Important: Emergency care is different. Since January 1, 2022, federal rules require emergency services to be covered without prior authorization, regardless of whether the provider or facility is in your plan’s network.
How the Process Works, Step by Step
- Your doctor decides you need a test, treatment or medication.
- Their office submits a request to your plan with supporting medical documentation. Confirm they used the correct plan name and member ID.
- The plan reviews the request and issues a decision.
- If approved, schedule the care and save the approval details, including any reference number, in your records.
- If denied, the plan must notify you in writing, within 15 days for a prior authorization request and within 30 days for services already received.
Keep in mind that approval is not the same as full payment. Depending on your plan, you may still owe a deductible, copayment or coinsurance; our guide to health insurance terms explains how each one works.
Timelines: How Long Your Insurer Has to Decide
Under the 2024 CMS Interoperability and Prior Authorization final rule, many plans, including Medicare Advantage, Medicaid and CHIP plans, must decide prior authorization requests for medical items and services (excluding drugs) as quickly as a patient’s condition requires. The maximum is 72 hours for expedited, urgent requests and seven calendar days for standard requests.
Those specific limits do not apply to Marketplace plans sold on the federally facilitated exchanges, so Marketplace timelines can differ; check your plan documents.
| Decision | Deadline |
|---|---|
| Expedited (urgent) request, Medicare Advantage, Medicaid and CHIP plans | 72 hours |
| Standard request, same plans | 7 calendar days |
| Written notice after a prior authorization denial | 15 days |
| Internal appeal, service not yet received | 30 days |
| Internal appeal, service already received | 60 days |
Helpful tip: If your condition is serious, ask your doctor’s office whether the request can be submitted as urgent. For many plans, an expedited review shortens the decision window from seven calendar days to 72 hours.
When a Request Is Denied: Appeals and External Review
You can file an internal appeal with your insurer. Complete the forms the plan requires, or write a letter that includes your name, claim number and health insurance ID number, and add supporting information, such as a letter from your doctor. In some states, the Consumer Assistance Program can file the appeal for you.
Keep records: denial letters or Explanation of Benefits forms, copies of everything you submit, any letter authorizing your doctor to appeal for you, and notes from phone calls, with dates, times and names. Send copies and keep the originals.
Reasons you can appeal include care the plan says is not a covered benefit, services from an out-of-network provider, loss of eligibility, and a plan moving to cancel your coverage retroactively. The appeal must be completed within 30 days for a service you have not yet received and within 60 days for one you have. If the plan still says no, its final determination must explain how to ask for an external review.
Questions to Ask Your Doctor and Insurer Before Treatment
Getting answers before treatment leaves time to fix problems while they are small.
For your doctor’s office:
- Will you handle the prior authorization, and have you confirmed my plan’s requirements?
- What documentation will you send?
- Should the request be submitted as urgent?
For your insurer:
- Does this service or medication require prior authorization under my plan?
- Is the provider or facility in network?
- What is the deadline for a decision, and can I get a reference number?
Prior authorization is one more difference between plans, and it is worth checking before you enroll. Our guide to buying health insurance on the ACA Marketplace covers how to compare plans during open enrollment or a special enrollment period.
Frequently asked questions
Does prior authorization guarantee my claim will be paid?
No. Approval means the plan agreed in advance that the service is covered, but your deductible, copayment or coinsurance may still apply. Keep the approval details with your records.
Who submits the prior authorization request?
Usually your doctor’s office submits the request to your plan with supporting medical documentation. Confirm they have your correct plan name and member ID.
What if I need care urgently?
Ask your doctor to request an expedited review. For many plans, urgent decisions are due within 72 hours instead of seven calendar days.
Do Marketplace plans follow the same deadlines as other plans?
Not always. The 72-hour and 7-day rules apply to plans such as Medicare Advantage, Medicaid and CHIP, so Marketplace plan timelines can differ. Check your plan documents.